- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $825.13 / $825.13 / $825.13
| Professional | | $825.13 | $825.13 | $825.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.00 / $1,712.00 / $2,498.00
| Professional | | $1,427.00 | $1,712.00 | $2,498.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.88 / $1,329.66 / $1,699.13
| Professional | | $914.88 | $1,329.66 | $1,699.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.54 / $1,788.64 / $2,906.65
| Professional | | $1,045.54 | $1,788.64 | $2,906.65 |